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InreMercedes-BenzEmissionsLitigationClassActionSettlementClaimFormClaimFormInstructionsRequiredDocumentation-FormerOwnersandLesseesFormerOwnersandLesseesmustincludeacopyofthefollowingsupportingdocumentationwithyourClaimFormtocompleteyourclaim.Pleasecheckthecorrespondingboxtoconfirmthatyouhaveincludedthespecifieddocumentationwithyourclaim.Pleasedonotsendtheoriginalsasthedocumentswillnotbereturnedtoyou.DOCUMENTSREQUIREDTOCOMPLETEYOURCLAIM*:OAcopyofyourdriver'slicenseorothergovernment-issuedphotoidentificationFullyexecutedIndividualRelease(acopyoftheIndividualReleaseisattachedtotheendofthisClaimForm)Proofthatyouownedorleased_andregisteredtheSubjectVehicleonorbeforeSeptember14,2020.Permitteddocumentationtoproveownershiporleaseincludesyourbillofsale,leaseagreement,title,registrationfromtimeofpurchaseorlease,DepartmentofMotorVehicles("DMV")registrationhistory,financingagreement,insurancedocumentationlistingyourdateofpurchaseorlease,orproofofleasepayment,insurancedocumentationmaysufficeforproofofregistration.YourdocumentationmustshowthedateyoupurchasedorleasedtheSubjectVehicle,aswellasthedateyouregisteredit.ProofthatyousoldortransferredtheSubjectVehicle(permitteddocumentsincludeyourbillofsale,trade-inreceipt,copyoftitletransfer,orproofofleasetermination)*Youmayneedtoprovideadditionaldocumentationincedaincircumstances.Youwillbenotifiedifadditionalinformationisneededtocompleteyourclaim.SECTIONE:CERTIFICATIONSTATEMENTFORENTIRECLAIMFORMALLCLAIMANTSMUSTCOMPLETEIunderstandthatinordertoobtainreliefundertheClassActionSettlements,Imustsignanddatethefollowingcertificationandprovidethedocumentationlistedabove.IrepresentandwarrantthatIhaveauthoritytosubmitaclaimfortheSubjectVehiclelistedabove,andthatanyofmyco-ownersandco-lesseesoftheSubjectVehiclelistedabovehavesignedthisClaimForm.IaffirmunderpenaltyofperjurythatallinformationinthisClaimFormistrueandaccuratetothebestofmyknowledge.SignatureDatePrintNameCURRENTOWNERSClaimFormsmustbesubmittedonlineatmbbluetecsettlement.comorpostmarkedORLESSEES:nolaterthanOctober1,2022.FORMEROWNERSClaimFormsmustbesubmittedonlineatmbbluetecsettlement.comorpostmarkedORLESSEES:byJuly12,2021,orbythedatetheCourtfinallyapprovestheMercedesClassActionSettlement(ifafterJuly12,2021).Pleasevisitmbbluetecsettlement.comforupdatesaboutthedeadlinetosubmityourclaim.Ifyouhavequestionsaboutfillingoutthisform,pleasevisitmbbluetecsettlement.comorcall1-877-313-0170ToviewJND'sprivacypolicy,pleasevisithttps://www.india.com/privacv-policv-6-